Neonatal Resuscitation by Dr Gabriel 2023

Based on standardized and global validated Guidelines

3. Neonatal and under -5 Deaths
Source: WHO global health estimates, 2019

4. Foundations of neonatal Resuscitation
•Afterbirth,thebaby'slungsmusttakeoverrespiratoryfunction.
•TheymustbefilledwithairtoexchangeoxygenandC02
•Respiratoryfailurecanoccurifthebabydoesnotinitiateorcannotmaintain
effectivebreathingeffort.
•Ifrespiratoryfailureoccurseitherbeforeorafterbirth,theprimaryproblemisa
lackofgasexchange.
•Therefore,thefocusofneonatalresuscitationiseffectiveventilationofthe
baby'slungs
Ventilation of the newborn's lungs is the single most important and effective
step in neonatal resuscitation.

5. Anticipating and preparing for Resuscitation
Before a baby is born
Prepare for birth

6. Anticipating and preparing for Resuscitation

7. Anticipating and preparing
for Resuscitation
Don’t forget to prepare also
emergency DRUGS (Epinephrine,
fluid for expansion,… )

8. Anticipating and preparing for Resuscitation
Pre-resuscitationteam briefing
• Assess risk factors.
• ldentifyteam leader.
• Anticipate potential complications and plan a team response.
• Delegate tasks.
• ldentifywho will document events as they occur.
• Determine what supplies and equipment will be needed.
• ldentifyhow to call for additional help

9. Initial steps of newborn care
Antenatal counseling
Team briefing
Equipment check
•Term?
•Tone?
•Breathing or crying? NOYES
Rapid Evaluation forEveryNewborn
A BIRTH
ANTICIPATION
BEFORE BIRTH
5 Initialsteps
+ Routineneonatal care
5 Initialsteps
+ Neonatal resuscitation
Immediately after birth
this’ not yet APGAR SCORE

10. Initial steps of newborn care
•Term?
•Tone?
•Breathing or crying? NOYES
Rapid Evaluation forEveryNewborn
A BIRTH
Continue
Routineneonatal care
Neonatal resuscitation
•Provide warmth
•Dry
•Stimulate
•Position the head and neck.
•Clear secretions if needed
5 initial steps
AIRWAY
TEMPERATURE

11. Continue Routineneonatal care
•Provide warmth
•Dry
•Stimulate.
•Position the head and neck.
•Clear secretions if needed
5 initial steps
AIRWAY
TEMPERATURE
After stimulation
Is the baby breathing well?
End of the first 30sec
A
+ Temperature
B
BREATHING
Routinecare
+ StartNeonatal resuscitation
YES
NO
Golden minute
30sec
30sec

12. Theneonateorinfantsensesheatlossasastressandrespondswithincreasedheatproductionandperipheral
vasoconstriction,withcentralizationofcirculation,inanefforttomaintainthecoretemperature
Mechanismsof heatloss
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

13. Hypothermia:
occurswhen,Heatlossesexceedheatproduction,droppingtheinfant’s
temperaturebelowthenormalrangeof36.5°to37.5°C(97.7°to99.5°F)
Hyperthermia:increase in the body temperature to above 37.5°C (99.5°F)
Mild hypothermia (cold stress): 36°to 36.4°C (96.8°to 97.5°F)
Moderate hypothermia: 32°to 35.9°C (89.6°to 96.6°F)
Severe hypothermia: Below 32°C (89.6°F)
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

14. Effectsof hypothermia
•Peripheralvasoconstriction(Acrocyanosis,pallor,andcoldnesstotouch)
•Respiratorydistress/apnea(astrongpulmonaryvasoconstrictorinducinghypoxemiaandcentralcyanosis)
•WithHypoxia,shifttoanaerobicmetabolismandlacticacidproduction
•PlusIncreasedoxygenconsumptionandmetabolicdemandsresultinmetabolicacidosis
•Mayevenleadtoarrhythmias(Bradycardiaanddeath)
•Depletionofcaloricreservesandhypoglycemia,…
However:Controlledhypothermiahasaneuroprotectiveeffectintermandnear-terminfantswith
moderatetoseverehypoxicischemicencephalopathy
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

15. Prevention of heat loss in the delivery room
•Warm environment, room temperature >25°C: Maintains temperature and reduces insensible water loss
(IWL) by 25%
•Radiant warmer
•Dry the skin with a prewarmed towel and thenremove any wet towels immediately
•Hats: Stockinettecaps?, Woolenhats,…
•The Neonatal Resuscitation Program and the International Liaison Committee on Resuscitation consensus
statement recommends the use of a plastic wrap in addition to standard techniques in the delivery room
for very–low-birth-weight infants
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

16. Occlusive plastic blankets/bags
Extremely low–birth-weight preterm newborn
wrapped in occlusive polyethylene sheet
during resuscitation.
Polyethylene bags (20 cm ×50 cm)
prevent evaporative heat loss in infants <29 weeks’ GA
Environment:Maintainstemperatureandreducesinsensiblewaterloss(IWL)by25%(24,25)
Access:Allowsneonatalresuscitation(secureairway,intubation,andchestcompressions),butvascularaccessislimited
Asepsis:Limitedbyaccess
Precautions:Recordcoretemperatureevery5to10minutesuntilinfantisstable
Complications:Hyperthermia,skinmaceration,riskofinfection

17. Radiant warmer bed: For unstable infants
Precautions:
Keep infant 80 to 90 cm from radiant heat
For premature infants, heat shielding must be added. Increase fluid infusions
To avoid burns, do not place oily substances on infant’s skin.
•Unimpeded access to infants receiving intensive care
•Ability to maintain infant position and wide sterile field;
•also allows assistants to participate
•Leave the baby uncovered to allow full visualization and to permit the
radiant heat to reach the baby.
Complications:
Hyperthermia, Dehydration, Burns, …
Unstable

18. Mechanisms of heat loss/gain in infants
during delivery room resuscitation and stabilization:
(A)
Conventional:
drying and placement under
Radiant warmer
(B)
Radiant warmer PLUS Vinyl bag.
(C) Radiant warmer PLUS
Thermal mattress

19. Resource-Limited Settings:
WHO Standard recommends measures to prevent hypothermia.
•Warm delivery rooms
•Immediate drying
•Skin-to-skin contact
•early breast-feeding
•Postponed bathing and weighing, appropriate clothing and bedding,
and warm transportation and resuscitation
•Kangaroo mother care (KMC)

20. Step 2: DRY
30sec
Initial steps
first 30sec
• Gently rub the back, trunk, or extremities
• No Overly vigorous stimulation, can cause injury.
• Never shake a baby
•Gentlydry withdry towelsor blankets
•If towel or blanket becomes wet, discard and use fresh
For extreme preterm < 32w GA :
should be covered immediately in polyethylene plasticif available and skip
drying by towels or blankets
Step 3: STIMULATE

21. Step 4: POSITION THE HEAD AND NECK TO OPEN AIRWAY
30sec
Initial steps
first 30sec
•Positionthebabyontheback(supine)
•Headandneckneutralorslightlyextended«sniffingthemorningair"position

22. Step 5: SUCTION, IF NEEDED
30sec
Initial steps
first 30sec
Suck oropharynx under direct vision
Do not do deep, blind suction (before first breath and drying/stimulating)
When ?
Routine suction for a crying, vigorous baby is not
indicated
Clear secretions from the airway only if :
•if the baby is not breathing
•if the baby is gasping
•if the baby has poor tone
•if secretions are obstructing the airway
•if the baby is having difficulty clearing their
secretions
•or if you anticípatestarting PPV.
How?
Suctioning gently with a bulb syringeupper airway
«Mouth before Nose"
How to Remember :
“M" comes before ”N" in the alphabet
Unnecessary suction
can be harmful.
Suction only if secretions
block mouth and nose
and you cannot ventilate
(WHO)

23. Routine care of newborn
•Provide warmth,
•Dry
•Stimulate.
•Position the head and neck.
•Clear secretions if needed
5 initial steps
If GoodTone, Breathing well, Crying
•Delayed of Clamping the cord (at 30
th
or 60
th
sec of life)
•Cord care, T-E-O ,…
•Give to the mother
Continue Routine care

24. Routine care of newborn
Formostvigoroustermandpretermnewborns,clampingtheumbilicalcord
shouldbedelayedforatleast30to60seconds.
30 Sec
30 Sec
Golden Minute
Delayed Clamping
the umbilical cord
(30 to 60sec)

25. •Term?
•Tone?
•Breathing or crying?
NO
Rapid Evaluation for Every Newborn
30 Sec
Airway & Temperature
Golden Minute
•Provide warmth,
•Dry
•Stimulate.
•Position the head and neck.
•Clear secretions if needed
Neonatal resuscitation at birth
30 Sec
Breathing (Second 30sec)
Apnea or Gasping
HR < 100 Bpm
Labored breathing
or persistent cyanosis
Positive Pressure Ventillation
Pulse Oximeter + cardiac monitor
Position airway + Suction if needed
Pulse oximeter
Oxygen if needed + Consider CPAP
Breathing
Second 30sec

26. After completing the initial steps,
positive-pressure ventilation (PPV)
is indicated if the baby is not
breathing, OR if the baby is gasping,
OR if the baby's heart rate is less
than 100 beats per minute (bpm)

27. Check the self-inflating bag and mask and the suction device
Golden minute Second 30sec

28. Breathing
Second 30sec
30sec

29. A
B C
Correct size face mask in the
correct position covers:
The nose
The mouth
The tip of the chin
BUT NOT THE EYES
Face mask that is too SMALL
Does not cover the nose
Does not cover the mouth
effectively
Face mask that is too LARGE
Covers the eyes
Extends over the tip of the chin
Correct mask size and position

30. Breathing
Second 30sec
30sec

31. For≥ 35Weeks ofGA: Resuscitationisinitiatedwithroomair (21% oxygen)
For< 35Weeks GA, resuscitationisinitiatedwith21 to30% oxygen
OxygenconcentrationforPPV
NeedsPPV+ connecttoO2
Breathing
Second 30sec
30sec

32. Positive PressureVentilation(PPV)
•Squeeze the bag smoothly between your thumb and 2 fingers, to produce a gentle movement of the chest
•Squeezethebag harderifyou need to deliver more air with each breath
•Effective PPV must inflates the lungs, this is evidenced by chest movement
Check the chest expansion
Breathing
Second 30sec
30sec

33. Positive PressureVentilation(PPV)
Give 40 to 60 breaths / min (count aloud)
Newlybornterminfant: 30 –40 cm H2O
Preterm: 20 –25 cmH2O
WhichPressure?
WhichRATE?
Breathing
Second 30sec
30sec

34. Positive PressureVentilation(PPV)
Breathing
Second 30sec
30sec
Give 40 to 60 breaths / min (count aloud)
Start PPV for 15sec
Assess HR
Do Ventillationcorrectives steps(MR. SOPA)
ResumePPV for 15sec
If HR <100bpm

35. The most important indicator of successful PPV is a rising heart rate
Rise of HR indicate good myocardial oxygenation
Sign of positive response to PPV
Breathing
Second 30sec
30sec
Check heart rate
Positive PressureVentilation(PPV)

36. PPV For how long?
15 Sec
15 Sec
Second 30seconds
Start PPV
Give 10 to 15 initial breaths (taking 15sec)
Re-assess
If HR is not increasing
Ventilation corrective steps (MR. SOPA)
And Resume PPV
Mask adjustment.
Reposition the head and neck.
Suction the mouth and nose.
Open the mouth.
Pressure increase.
Alternative airway.
Re-assess
Resume PPV for 15sec

37. Target Pre-ductal Oxygen saturation
Measured on
the Right arm
Preductal SpO2
Postductal
SpO2

38. First APGAR SCORE

39. First APGAR SCORE
Reported at 1minute and 5minutes after birth for all infants and,
Infants with a score less than7: at 5-minute intervals thereafter until 20
minutes.
Interpretation at 5 minutes:
7 -10: reassuring or normal
4 –6: moderately abnormal
0 -3: Low (term infant and late-preterm infant)

40. 30 sec 30 sec
Birth
Initial Step
A B C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 -100
Third 30sec of life
C
PUT ALTERNATIVE AIRWAY, IF AVAILABLE
Ie. Place Laryngeal Mask
ContinousPPV with Laryngeal Mask for 30sec
i.eEndotracheal intubation, if no improvement
INCREASE OXYGEN UP To 100%
Always remember
Ventilationofthenewborn'slungsisthe
singlemostimportantandeffective
stepinneonatalresuscitation.

41. Alternative airway
Laryngeal mask

42. Insertion of an endotracheal tube (intubation) is strongly recommended if the baby's heart rate remains
less than 100 bpm and is not increasing after positive-pressure ventilation (PPV) with a face mask or
laryngeal mask.
ETT
AHA 2020 Guidelines

43. •ChestcompressionsalwaysaccompainedbyIPPV
•Usingoxygenconcentration:
Shouldbe increasedup to100%
Chestcompression-ventilationsrateis3:1(90 by30 per minute)
30 sec 30 sec
Birth
Initial Step
A B
C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 -100
Third 30sec of life
If Alternative Airway not
available, pass to coordinated
PPV + Chest compressions

44. 1 rescuer
2 fingers in the center of the
chest, below the nipple line
2 or more rescuers
2 thumb–encircling hands in the
center of the chest, below the
nipple line
Chest compressions
30sec
Third
30sec

45. How deeply?
Depth : 1/3 of A-P Chest Diameter
CoordinatedCompressions and Ventilations
Chest compressions
Second
minute
3 compressions + 1 ventilation every2 seconds

46. What is the compression rate?
90 compressionsper minute
3 compressions + 1 ventilation every2 seconds
CoordinatedCompressions and Ventilations
The rhythm by counting out loud:
"One-and-Two-and-Three-and-Breathe-and; One-and-Two-and-Three-and-Breathe-and; …11
• Compress the chest with each counted number ("One, Two, Three").
• Release the chest between each number ("-and-").
• Pause compressions and give a positive-pressure breath when the compressor calls out "breathe-and. 11
30sec
Third
30sec
If necessary increase the Oxygen supplementation to 100% (if alternative airway is in place)

47. DRUGS
30 sec 30 sec
Birth
Initial Step
A B
C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 -100
EI
Drugs
HR < 60bpm
Color
RR
Drugs are indicated HR remains < 60bpm after:
•At least 30 seconds of PPV that inflates the lungs as evidenced by chest movement
•and Another 60 seconds of chest compressions coordinated with PPV using 100%oxygen
DRUGS are not indicated before you have established ventilation that effectively inflates the lungs.
THE QUALITY OF VENTILATION MATTERS (Do things Properly) NEED PRACTICE FOR IMPROVING SKILLS

48. The superficial venous system
in the neonate.
Get a Vascular access < 90sec
For emergency drugs and fluid administrations
The Vascular access should be ready
in less than 90sec after birth:
Why 90sec?
Drugs should be started if HR remain
<6obpm after :
Initial steps (30sec)
+ PPV (30sec)
+ PPV/Compression (30sec)
Start to look for the IV access before 90sec

49. Correct application of a tourniquet for quick release

50. Rapid option
Get a Vascular access < 90sec
For emergency drugs and fluid administrations
Umbilical vein
Correct (A and B)
and incorrect (C) umbilical venous catheter insertion

51. 1 2
3
lnsertionusing
an intraosseous drill
4
5
Intraosseous emergency route

52. Epinephrine
10 ml syringe
9ml ofNormal
Saline (0.9%)
Results:
1mg/10 ml
= 0.1mg/1ml
= 0.01mg/0.1ml
Ampule
1 mg /1 mL
+
IV (prefered) or IO
Dose = 0.02 mg/kg
(equal to 0.2 mL/kg)
Range = 0.01 to 0.03 mg/kg
(equal to 0.1 to 0.3 mL/kg)
May repeat every 3 to 5 minutes
flush3-mL saline,Can Follow
Alternative: ETT:
0.05mg-0.1mg/Kg (0.3 –1ml/Kg)
(1:10000)
(1:1000)
Indication
EpinephrineisindicatedifHRremains<60bpmafter:
•Atleast30secofPPVthatinflatesthelungsasevidencedbychestmovement
•andAnother60secofchestcompressionscoordinatedwithPPVusing100%oxygen

53. Volume expansion
•Normal saline bolus: 10ml/Kg
over5 –10 minutes
Can be repeated
•Othersolutions: Ringer´s
lactateorRh.negativeblood
If severe blood
lossand/oranemia is
suspected or documented
• Administration of a volume expander is indicated
if the baby is not responding to the steps of
resuscitation and there are signs of shock or a
history of acute blood loss.
• Volume expanders should not be given routinely
during resuscitation in the absence of shock or a
history of acute blood loss.

54. Pass NG tube or Orogastric tube
if Prolonged PPV or need of continuous CPAP
If you continue face-mask PPV or continuous positive airway pressure (CPAP)
for more than several minutes, an orogastric tube should be inserted to act as
a vent for gas in the stomach.

55. What do you do if the baby is not improving after giving
intravenous epinephrine and volume expander?
1. Is the chest moving with each breath?
2. Is the airway secured with an endotracheal tube oral laryngeal mask?
3. Are 3 compressions coordinated with 1 ventilation being delivered every 2 seconds?
4. Is the depth of compressions one-third of the AP diameter of the chest?
5. Is 100% oxygen being administered through the PPV device?
6. Was the correct dose of epinephrine given intravenously?
7. Is the umbilical venous catheter or intraosseous needle in place or has it been dislodged?
8. Is a pneumothorax present?

56. When to stop resuscitation ?
Positive response
•HR > 100*
•Spontanuousrespirations*
•Fairmuscle tone
•AppropriatetargetSpO2 (if not, can requiresto continousO2 supplementation,
CPAP, … )
Negativeresponse
HR < 30 or Undetectable
No signal pulse oxymeter
+No spontanousrespiration
+No muscules tone, pallor
AfterwelldoneResuscitativeefforts (properly) for 10min or 20min (If Therapeutic
Hypothermia)
NEXT STEP
Post resuscitationcare

57. When to stop resuscitation ?
In high resources Setting, at the THERAPEUTIC HYPOTHERMIA ERA
•Previous editions of the AHA Textbook of Neonatal Resuscitation suggested that it may be reasonable
to stop resuscitative efforts if the heart rate was undetectable after 10 minutes of resuscitation.
•The 2020 editionAHA Textbook of Neonatal Resuscitation suggests that the time interval to consider
stopping resuscitative efforts should be around 20 minutes:
Improvements in neonatal intensive care and the availability of neuroprotective interventions, such as
therapeutichypothermia, may be improving the long-term outcome for these newborns. BY Extending the
time frame to consider discontinuing Resuscitative efforts

58. Post resuscitation interventions
•Maintain temperature: Avoid overheating the baby during or after resuscitation
In case of severe birth asphyxia related HIE, hypothermia can be beneficial (selection of candidates
for therapeutic hypothermia)
•Continuous monitoring of vital signs (Tº,HR, RR, BP, sPO2,…), respiratory status, urine output,
neurologic status, ABGs,
•Investigations / eventual complications of perinatal distress/asphyxia:RBS, RFTs, Serum
Electrolytes, LFTs, serum PH, Arterial Blood Gas (ABGs), baseline CBC, …
•Assess the need to maintain continuous supplemental oxygen, PPV, or continuous positive
airway pressure (CPAP), or other advanced / specialized interventions, …

60. •Pneumothorax or pleural effusion
•Airway obstruction: thick secretions, MAS, Choanal Atresia, Pierre-Robin
Sequence
•Complications from maternal opiate or anesthetic exposure
•NTD: Myelomeningocele
•Abdominal walldefect
Neonatal Resusciatationin Special Considerations
Discussed Separately in another session

61. References

62. #Merci
#Asante
#Thank you
[email protected]